Treatment Options in Late-Life Treatment-Resistant Depression

TABLE. The incidence of treatment-resistant depression as reported by survey takers

Figure 1 and 2: Percentage of practice consisting of patients with TRD. Percentage of TRD patients aged 60+ years.

Depression is a major public health issue and is associated with significant morbidity, mortality, and economic burden. It is the third-greatest contributor to global disease burden1 and affects both low- and high-income countries, with a 12-month prevalence of 5.9% and 5.5%, respectively.2 There is a relative paucity of information on treatment of late-life treatment-resistant depression (TRD). We conducted a survey of the readership of Psychiatric Times to assess the general attitudes toward the prevalence of—and the existing treatment approaches toward—TRD in adults 60 years and older.

Here we present the results of that survey and discuss the strengths and weaknesses of various approaches to TRD management.

What the survey revealed

The online survey received 468 responses: 51.6% respondents identified as psychiatrists, 7.7% as psychologists, and 14% as other mental health professionals. The US was well represented, contributing 79.3% of responses: 25.1% came from the Northeast, 16.2% from the Southeast, 17.2% from the Midwest, 8.1% from the Southwest, and 12.7 from the West. The remaining 20.7% of responses came from 41 countries, including Australia, the UK, Canada, and India. Of the respondents, 36.4% had been practicing for more than 25 years. Approximately one-third were in their first decade of practice, and one-third were in their second decade of practice.

The Table shows the incidence of TRD as reported by survey takers. Figure 1 shows the percentages of patients with TRD, and Figure 2 shows the percentages of TRD patients 60 years and older in the respondents’ practices.

Question from survey: Please rate how helpful you would find the results of a large randomized study that compares the risks and benefits of augmentation and switching strategies for TRD in patients who are 60+ years old.

Most (71.7%) respondents stated that such a study would be “helpful,” and 61% would find it “extremely helpful.” Importantly, 76.6% of respondents believe their practice would benefit from the findings of such a study.

Question from survey: What treatment choices would you like to see in a randomized study for TRD in patients who are 60+ years old?

The most popular options were augmentation with aripiprazole (53.5%), augmentation with bupropion (49.2%), and augmentation with lithium (45.2%). Switching to bupropion and nortriptyline options were less popular, and each scored 28.4%.

Over one-third of respondents suggested alternative treatment options to be studied. The most common suggestions were psychotherapy; augmentation with antipsychotics; transcranial magnetic stimulation (TMS) and deep brain stimulation (DBS); ECT; the addition of a second antidepressant, both typical (SSRI, SNRI, TCA, MAOI) and atypical (mirtazapine), and newer agents (vortioxetine); as well as methylphenidate and other stimulants, ketamine, and lamotrigine.

Several respondents suggested supplementation with thyroid hormone and, less frequently, folate and omega 3. Other drugs named were memantine, pramipexole, pindolol, nefazodone, buspirone, and glutaminergics. Finally, lifestyle measures such as exercise and various complementary and alternative practices, including acupuncture, were also suggested.

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Dr Arandjelovic is a Medical Doctor and Researcher at the IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, Victoria, Australia. Dr Eyre is an Adjunct Research Fellow at the IMPACT Strategic Research Centre; the College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; and the Semel Institute for Neuroscience and Human Behaviour at UCLA. Dr Forbes is an Adjunct Research Fellow at the College of Medicine and Dentistry, James Cook University. Dr Lavretsky is Professor of Psychiatry at the Semel Institute in Los Angeles, where she directs the Late-Life Mood Stress and Wellness Research Program.